Dependent Care Travel Grant Program Application

* Indicates required field

I understand that this form is collecting my information, including my personal data in order to be considered for the MagLab Dependent Care Travel Grant Program.

Applicant Information

(xxx)xxx-xxxx

Event Information

Maximum 500 characters.
Click in the text box, then select the date.
Correct format is yyyy-mm-dd
Click in the text box, then select the date.
Correct format is yyyy-mm-dd

Describe your role in the event and how the event is important to advancing your career.*

Please do not copy and paste text directly from MS Word. Instead, either type directly into the form, or use a text editor program with no text formatting.

Maximum 1200 characters.

Grant Request Information

Describe the travel and accommodations for dependents and/or coverage for planned care that you are requesting.*

No $ and no comma; e.g. 12000.00
No $ and no comma; e.g. 12000.00
No $ and no comma; e.g. 12000.00
No $ and no comma; e.g. 12000.00
No $ and no comma; e.g. 12000.00
No $ and no comma; e.g. 12000.00

Regular Dependent and/or Planned Care Coverage

Describe your regular dependent and/or planned coverage.*

Maximum 1200 characters.

Dependents Information

(If you only have one dependent, then you only need to complete one section.)


Maximum 500 characters


Last modified on 7 April 2016